INSULAR HEALTH CARE, INC.

2/F Insular Health Care Inc. Bldg.

167 Dela Rosa cor. Legazpi Sts., Legazpi Village
Makati City 1229, Philippines
Trunk Line (02)8130131 Fax No. (02) 8137856
www.insularhealthcare.com.ph

FRANCHISE APPLICATION FORM

PLEASE PROVIDE ALL INFORMATION. INCOMPLETE FORM WILL NOT BE PROCESSED. TYPE OF GROUP:
DATE: JANUARY 22, 2020 / EMPLOYER-EMPLOYEE

PRINTED NAME OF COMPANY : SEVEN SEVEN GLOBAL SERVICES, INC ASSOCIATION / COOPERATIVE

UNION Others : _______________________

ADDRESS : 27th Floor The Orient Square Building, F. Ortigas Avenue

Ortigas Center, Pasig City TYPE OF PAYMENT ARRANGEMENT

SUBSIDIARIES / AFFILIATES TO BE ENROLLED (if any): EMPL. DEP.

100% TO BE PAID BY EMPLOYER

CLIENT'S TELEPHONE NUMBER: CONTRIBUTORY : Employer (_____%) / Employee (_____%)

Mou

E-MAIL ADDRESS: rmontealto@77global.biz 100% TO BE PAID BY EMPLOYEES (VOLUNTARY) / THRU SALARY DEDUCTION

NATURE OF BUSINESS: IT Outsourcing PLAN SPECIFICATION (Terms Of Reference may be attached to this form)

CONTACT PERSON: MR. RODISENDO S. MONTEALTO, JR. Yes PREPARE PROPOSAL FOR STANDARD BENEFITS

DESIGNATION: HR Specialist PREPARE PROPOSAL WITH THE FOLLOWING SPECIFICATIONS :

PROPOSAL ADDRESSEE: MR. RODISENDO S. MONTEALTO, JR. Plan "A" with AHMC, CSMC, MMC, SLMC-QC, TMC EXCEPT SLMC-GC

DESIGNATION: HR Specialist / Plan "A" with AHMC, CSMC, MMC, SLMC-QC, TMC & SLMC-GC
Plan "A" without AHMC, CSMC, MMC, SLMC-QC, TMC & SLMC-GC,

TOTAL NUMBER OF REGULAR EMPLOYEES 600 Plan "A" without AHMC, CSMC, MMC, SLMC-QC, TMC & SLMC-GC, CDH, CHH & DDH
TOTAL NUMBER TO BE ENROLLED 600 EMERGENCY CARE SERVICES:

Principal Members / Dependent300 IN NON-ACCREDITED HOSPITAL :

COMPANY CLASSIFICATION: % OF REIMBURSEMENT : 100%
PRIVATE / GOVERNMENT NGO MAXIMUM AMOUNT OF REIMB. :
ZERO RATED ENTITY YES NO IN FOREIGN TERRITORY :
VAT EXEMPT ENTITY / YES NO % OF REIMBURSEMENT : 100%
MAXIMUM AMOUNT OF REIMB. :
EXISTING / PREVIOUS HMO PROVIDER : Intellicare
EXPIRATION DATE : ### OPTIONAL BENEFITS (RIDER):
EXISTING / PREVIOUS HEALTH CARE PROGRAM: / WITH DENTAL RIDER
For Principals: For Dependents: WITHOUT DENTAL RIDER
/ HMO / HMO TERM INSURANCE FACE AMOUNT :
SELF INSURED SELF INSURED AD&D FACE AMOUNT :
OTHERS : OTHERS PRESCRIPTION MEDS LIMIT / MEMBER:
MATERNITY RIDER
REQUEST FOR HEALTH CARE PROGRAM : NORMAL DELIVERY LIMIT :
Yes HMO (COMPREHENSIVE) CAESARIAN DELIVERY LIMIT :
HMO (Unbundled IP/OP) OTHERS : LIMIT :
Cost Plus Program (CPP) / Third Party Administration (TPA) TOTAL NUMBER OF FEMALE ENROLLEES (minimum of 25)
Others FEMALE EMPLOYEES
FEMALE SPOUSES
PROPOSED PLAN :
PRINCIPALS DEPENDENTS
EMPLOYEE LEVEL / ROOM # OF EMPLOYEES TO BE
MBL DEPENDENT LEVEL ROOM ACCOMMODATION MBL # OF DEPENDENTS TO BE ENROLLED
CLASSIFICATION ACCOMMODATION ENROLLED

This is to confirm that I have read and understood the company's franchising rules and procedures and shall abide by them.
I hereby declare that the above information are true & correct to the best of my knowledge & ability and I shall conduct myself in accordance
with all the rules, regulations and company policies of Insular Health Care at all times.

RODISENDO S. MONTEALTO JR ### AGENT / BROKER'S CODE NO.

PRINTED NAME & SIGNATURE OF INTERMEDIARY DATE CONTACT NO. U
INTERMEDIARY CLASSIFICATION FOR INSULAR HEALTH CARE DIRECT SALES AGENTS FOR INSULAR LIFE AGENTS

AGENT NAME OF UNIT SALES MANAGER NAME OF UNIT MANAGER

BROKER / GENERAL AGENCY
DIRECT NAME OF GROUP SALES MANAGER NAME OF DISTRICT MANAGER / G.A. HEAD
FOR CDSSD USE ONLY

FRANCHISE STATUS : ATTACHMENTS : REMARKS : DATE RECEIVED :

OPEN FOR FRANCHISE EMPLOYEE MASTERLIST APPROVED VERIFIED BY :

CLOSED FRANCHISE TERMS OF REFERENCE (TOR) DISAPPROVED DATE VERIFIED :

CURRENTLY ENROLLED CLAIMS UTILIZATION REPORT ON HOLD APPROVED BY :

WITH PREVIOUS POLICY BOR / AOR DATE APPROVED :

FRANCHISE
LAST EXPIRATION DATE LAST FRANCHISED DATE EXPIRATION DATE :
 INSULAR HEALTH CARE, INC.
2/F Insular Health Care Inc. Bldg.
167 Dela Rosa cor. Legazpi Sts., Legazpi Village
Makati City 1229, Philippines
Trunk Line (02)8130131 Fax No. (02) 8137856
www.insularhealthcare.com.ph

REQUEST FOR EXTENSION OF FRANCHISE FORM

NAME OF COMPANY / INSTITUTION :

DATE OF APPROVAL OF INITIAL FRANCHISE :

DATE OF EXPIRATION OF INITIAL FRANCHISE :

REASON FOR REQUEST OF EXTENSION OF FRANCHISE :

STATUS OF NEGOTIATION OF ACCOUNT :

VALIDATION OF ASSIGNED ACCOUNT EXECUTIVE :

AGENT / BROKER'S CODE NO.

PRINTED NAME OF INTERMEDIARY

DATE CONTACT NO.

FOR MSSD USE ONLY

STATUS OF FRANCHISE (FRANCHISING SYSTEM)

REMARKS : RECEIVED :

1ST REQUEST FOR EXTENSION NEW EXPIRATION OF FRANCHISE : APPROVED VERIFIED :

2nd REQUEST FOR EXTENSION NEW EXPIRATION OF FRANCHISE : DISAPPROVED DATE :

HOLD APPROVED :

DATE :

INSULAR HEALTH CARE, INC.

2/F Insular Health Care Inc. Bldg.
167 Dela Rosa cor. Legazpi Sts., Legazpi Village
Makati City 1229, Philippines
Trunk Line (02)8130131 Fax No. (02) 8137856
www.insularhealthcare.com.ph

REQUEST FOR EXTENSION OF FRANCHISE FORM

NAME OF COMPANY / INSTITUTION :

DATE OF APPROVAL OF INTIAL FRANCHISE :

DATE OF EXPIRATION OF INITIAL FRANCHISE :

REASON FOR REQUEST OF EXTENSION OF FRANCHISE :

STATUS OF NEGOTIATION OF ACCOUNT :

VALIDATION OF ASSIGNED ACCOUNT EXECUTIVE :

AGENT / BROKER'S CODE NO.

PRINTED NAME OF INTERMEDIARY

DATE CONTACT NO.

FOR MSSD USE ONLY

STATUS OF FRANCHISE (FRANCHISING SYSTEM)

REMARKS : RECEIVED :

1ST REQUEST FOR EXTENSION NEW EXPIRATION OF FRANCHISE : APPROVED VERIFIED :

2nd REQUEST FOR EXTENSION NEW EXPIRATION OF FRANCHISE : DISAPPROVED DATE :

HOLD APPROVED :

DATE :